CARE RECIPIENT WAIVER

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REVIEW AND ACKNOWLEDGE

This waiver should only be signed after you have been referred for care and CDAIDE has requested you complete it.

If you have been asked to complete our income verification form ONLY, please click here.

 

CDAIDE’s support may include financial aid for urgent needs, access to health care, connection

to community resources, mentoring, counseling, and other measures to meet individual needs.

All of our services are offered with no strings attached.

CDAIDE takes your privacy seriously and wants to inform you about the protection of your

personal information. All volunteers and board members have signed a confidentiality

statement and understand that protecting your privacy is essential.

In consideration of my use of the services of CDAIDE, I for myself, my heirs, personal

representatives or assigns, do hereby release, waive, discharge, and covenant not to sue

CDAIDE and its directors, officers, employees and agents from liability from any and all all

claims including negligence resulting in personal injury, accidents, or illnesses (including death)

and property loss arising from use of CDAIDE’s services.

WAIVER
 

I hereby give permission to CDAIDE to share my circumstances and personal details (including

any identifying information I provide) with CDAIDE board members, relevant volunteers, the

individual who referred me for support, and Care Partners (such as physicians, counselors, etc.)

that might assist with my needs. This may involve referral and sharing of personal information

to other organizations that I agree to. Data on CDAIDE’s assistance and my personal

information will also be stored in CDAIDE’s database and in a charity tracking database, which

allows local agencies to collaborate. Demographic data may be shared with funding agencies.

No identifying details about my story, situation or personal information will be shared publicly

without an optional Media Release signed by me, if I wish to share my story more broadly to

assist others.

Driver's License Upload

 

Please upload your driver’s license for identity verification. This step is required for CDAIDE to approve care. File types supported include image files such as JPG, JPEG & PNG.

Upload License

Bill Documentation

 

Please provide documentation for the items that you most need assistance with (a lease with your name and rent amount if you need rent support, a utility bill, car payment bill, etc), which is needed to assess your needs as part of the review process. This in no way implies that support is guaranteed, but will save time later should support be approved. File types supported include image files such as JPG, JPEG & PNG.

Upload Bill Doc 1
Upload Bill Doc 2
Upload Bill Doc 3
Upload Bill Doc 4
Upload Bill Doc 5

Address Verification

 

To verify your address, we need a copy of a recent utility bill, lease, car registration, phone bill or mortgage with your name and current address (or other documentation if these are not available). File types supported include image files such as JPG, JPEG & PNG.

Upload File

Demographic Data

 

The following demographic questions are REQUIRED by grantors that support CDAIDE. Your answers are confidential and have no bearing on support you may receive from CDAIDE.

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NOT INCLUDING YOURSELF, how many other family members live in your household (including dependents)?

We have room below to capture 6 additional family members. If your number is greater than 6, we will contact you for the additional info.

Add Family Members

 

To approve support, data on all members of the household is REQUIRED.  Please check the box for each family member you will be adding and the data entry fields will appear below.

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Income Data

 

The following income information is requested to ensure compliance with the U.S. Department of Housing and Urban Development Community Development Block Grant requirements. Your answers are confidential.

Please upload your two most recent paystubs from every job you hold, and those held by other members of your household. If you have only one paystub available, upload that for each job. File types supported include image files such as JPG, JPEG & PNG.

Upload Paystub 1
Upload Paystub 2
Upload Paystub 3
Upload Paystub 4
Upload Paystub 5
Upload Paystub 6

You are REQUIRED to self-report your annual income. Income is defined as the total of all the adult household members’ gross income that is anticipated to be received during the coming 12-month period. Income includes things such as wages, tips, social security payments, alimony, child support, and the income generated by an asset such as bank accounts or a 401(k).

NOTE: The information provided on this form is subject to verification by HUD at any time, and Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony and assistance can be terminated for knowingly and willingly making a false or fraudulent statement to a department of the United States Government.

Thanks for submitting!

If you plan to meet in person with any CDAIDE staff member or volunteer, please complete our COVID waiver.